It’s likely you’ve seen the nation’s opioid epidemic in the news lately, as opioid use, use disorder, and overdose has vastly increased in the past several years. [1, 2, 3, 4, 6] The rate of women’s and pregnant women’s use and misuse of opioids have paralleled this increase. [4, 5, 6]
Neonatal Abstinence Syndrome (NAS)
Additionally, the incidence of infants born dependent on opioids (referred to as Neonatal Abstinence Syndrome or NAS) as a result of the mother’s opioid use during pregnancy has also greatly increased. [4, 5, 6]
It is estimated that anywhere from 50 to 80 percent of opioid-exposed infants develop NAS. [6]. This increase of NAS has been associated with increases in the prescription of opioids to pregnant women for pain, which doubled between 1995 and 2009. [4]
Mothers & Opioid Abuse
Use of opiates during pregnancy can result in a drug withdrawal syndrome in newborns called neonatal abstinence syndrome (NAS). A new study to determine the extent, context and costs of NAS found that incidence of NAS is rising in the United States.
There was a five-fold increase in the proportion of babies born with NAS from 2000 to 2012 when an estimated 21,732 infants were born with NAS —equivalent to one baby suffering from opiate withdrawal born every 25 minutes.
Newborns with NAS were more likely than other babies to also have low birthweight and respiratory complications. The number of delivering mothers using or dependent on opiates rose nearly five-fold from 2000 to 2009, to an estimated 23,009.
In 2012, newborns with NAS stayed in the hospital an average of 16.9 days (compared to 2.1. days for other newborns), costing hospitals an estimated $1.5 billion.
The majority of these charges (81%) were paid by state Medicaid programs, reflecting the greater tendency of opiate-abusing mothers to be from lower-income communities. The rising frequency (and costs) of drug withdrawal in newborns points to the need for measures to reduce antenatal exposure to opiates.
National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services.
Top Graph: Every 25 minutes, 1 baby is born suffering from opiate withdrawal.
Bottom Left Graph: Average length or cost of hospital stay graph. Newborns with NAS stayed in the hospital for an average of 16.9 days compared to 2.1 days for those without NAS. The hospital costs for newborns with NAS were $66,700 on average compared to $3,500 for those without NAS.
Bottom Right Graph: NAS and maternal opiate use on the rise graph. The rate of babies born with NAS per 1,000 hospital births was 1.2 in 2000, 1.5 in 2003, 1.96 in 2006, 3.39 in 2009 and 5.8 in 2012. The rate of maternal opiate use per 1,000 hospital births was 1.19 in 2000, 1.26 in 2003, 2.52 in 2006, and 5.63 in 2009.
Understanding the Power of Opioids
Opioids are a class of drugs that include illegal drugs like heroin as well as prescription drugs like fentanyl, oxycodone (OxyContin®), hydrocodone (Vicodin®), codeine, morphine, and many others. [7]
Although not everyone who is prescribed or has tried opioids develop an opioid use disorder, opioids are highly physically and psychologically addictive due to their powerful ability to reduce physical pain and induce feelings of euphoria. [7]
So, even if a mother is taking opioids as prescribed by her doctor, she can develop opioid dependence. Recent studies have noted that the prescription of opioids to pregnant women for pain has doubled between 1995 and 2009. [4]
Related Disorders
Depression, anxiety, trauma-related, and other psychiatric disorders are common among women who struggle with opioid use disorders. [6] Research has found that the majority of women entering treatment for opioid use have a history of sexual assault, trauma, or domestic violence and/or come from homes where their caregivers used drugs. [4]
Risk to Infants
Due to fluctuating levels of opioids in the blood of mothers misusing opioids, unborn infants are exposed to repeated periods of withdrawal. This can harm the function of the placenta and increase the risk of [4]
- fetal growth restrictio
n - placental abruption
- preterm labor
- fetal convulsions
- intrauterine passage of meconium
- fetal death
In addition to these direct physical effects, other associated risks to unborn infants include: [4]
- untreated maternal infections such as HIV
- malnutrition and poor prenatal care
- dangers conferred by drug-seeking lifestyle, including violence and incarceration
Treatment
Typically, the goal of treating pregnant mothers with opioid dependence is to lessen the medical risks to their unborn infants. Since the late 1990s, the standard medication-assisted treatment has been methadone.
However, recent evidence supports the use of buprenorphine as a more beneficial medication-assisted treatment option. NAS still occurs in babies whose mothers have received buprenorphine or methadone, but it is less severe than it would be in the absence of treatment.
Currently, research indicates no known risk of increased birth defects associated with the use of buprenorphine or methadone. [4, 6]
Both methadone and buprenorphine treatment during pregnancy: [4]
- stabilize fetal levels of opioids, reducing repeated prenatal withdrawal
- improve neonatal outcomes
- increase maternal HIV treatment to reduce the likelihood of transmitting the virus to the fetus
- connect mothers to better prenatal care
A meta-analysis showed that, compared to single-dose methadone treatment, buprenorphine resulted in: [4]
-
ten percent lower incidence of NAS - shorter neonatal treatment time (an average of 8.4 days shorter)
- lower amount of morphine used for NAS treatment (an average of 3.6 mg lower)
- higher gestational age, weight, and head circumference at birth
Other interventions to help mothers with opioid abuse and associated use disorders include: [6]
- education of risks: social, legal, and medical consequences, including NAS
- behavioral health intervention and treatment
- counseling and peer support
- psychopharmacological treatment for any co-morbid psychiatric disorder
- postpartum planning (e.g., creating a healthy home environment, breastfeeding, education on NAS and infant withdraw symptoms, infant care, contraceptives)
Effective prevention and treatment strategies exist for opioid misuse and use disorder but are highly underutilized across the United States. [4] Lawmakers, as well as medical and mental health professionals, continue to work to address the opioid epidemic and help mothers who are struggling with opioid use.
Substance Abuse and Mental Health Services Administration (SAMHSA), has recently published Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants, [6] which is an excellent resource for providers working with mother’s struggling with opioid use disorder.
About the Author:
Chelsea Fielder-Jenks is a Licensed Professional Counselor in private practice in Austin, Texas. Chelsea works with individuals, families, and groups primarily from a Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) framework. She has extensive experience working with adolescents, families, and adults who struggle with eating, substance use, and various co-occurring mental health disorders. You can learn more about Chelsea and her private practice at ThriveCounselingAustin.com.
References:
1. Substance Abuse Center for Behavioral Health Statistics and Quality. (2017, Sept 7). Results from the 2016 National Survey on Drug Use and Health: Detailed Tables. SAMHSA. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.htm. on 2018, May 11.
2. Rudd, R.A., Aleshire, N., Zibbell, J.E., Gladden, R.M. (2016). Increases in Drug and Opioid Overdose Deaths–United States, 2000-2014. MMWR Morb Mortal Wkly Report; 64 (50-51): 1378-1382. doi:10.15585/mmwr.mm6450a3.
3. Rudd, R.A., Seth, P., David, F., Scholl, L. (2016). Increases in Drug and Opioid-Involved Overdose Deaths – United States, 2010-2015. MMWR Morb Mortal Wkly Report; 65 (50-51) : 1445-1452. doi:10.15585/mmwr.mm655051e1.
4. NIDA. (2018, March 30). Medications to Treat Opioid Use Disorder. Retrieved from https://www.drugabuse.gov/publications/research-reports/medications-to-treat-opioid-use-disorder on 2018, May 11.
5. Tolia, V.N., Patrick, S.W., Bennett, M.M., et al. (2015). Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. New England Journal of Medicine; 372(22):2118-2126. doi:10.1056/NEJMsa1500439.
6. SAMSHA. (2018, Jan 18). Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. Retrieved from https://store.samhsa.gov/shin/content//SMA18-5054/SMA18-5054.pdf on 2018, May 11.
7. NIDA. Opioids. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids on 2018, May 11.
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We at Addiction Hope understand that addictions result from a combination of environmental and genetic factors. If you or a loved one are suffering from an addiction, please know that there is hope for you, and seek immediate professional help.
Published on June 21, 2018
Reviewed on June 21, 2018 by Jacquelyn Ekern, MS, LPC
Published on AddictionHope.com